Reentry Health Plus Care Manager

Overview

The HH+ Case Manager works with members and their network of providers to help minimize care barriers and improve health outcomes through interventions such as care coordination, motivational interviewing, and health promotion. They facilitate independent health management for clients over time and participate in agency-wide quality improvement activities for individuals with chronic illness, behavioral health issues, and homelessness.

• Guide clients with chronic illness and/or prior justice involvement through the health care system via in‑person engagement, case coordination, and ongoing relationship building.
• Conduct comprehensive initial assessments and annual re‑assessments of clients’ medical, mental health, substance use, financial, housing, and support needs in community, home, clinical, or office settings.
• Manage a caseload of 20 clients with high care needs.
• Develop and maintain individualized, patient‑centered care plans with client and provider input; update plans every 3–6 months or when new needs arise, per Health Home standards.
• Collaborate with medical and behavioral health providers through face‑to‑face meetings and coordinated care activities to implement and monitor plans for chronic conditions such as diabetes, asthma, CHF, hypertension, behavioral health conditions, HIV, and other complex health needs.
• Engage clients in reviewing housing options based on program eligibility and provide hands‑on assistance with housing applications and related activities.
• Address benefits‑related needs (Medicaid, HRA, SNAP, medical transportation, other entitlement programs) through direct client support and advocacy.
• Conduct regular home and field visits to maintain client engagement and assess evolving needs.
• Coordinate client services with internal and external providers through regular, in‑person or hybrid case conferences at least quarterly.
• Document all in‑person activities, outcomes, and care‑plan progress in the case record with timely accuracy.
• Maintain strict confidentiality in all client interactions and records.
• Perform other duties as assigned.

• Proficiency with Microsoft Office products; prior experience with EHRs is a plus.
• Excellent written and oral communication skills.
• Strong organization and multi‑tasking abilities.
• Positive, adaptable attitude toward staff and clients.
• Independent worker who can prioritize multiple responsibilities in a fast‑paced environment.
• Comfortable working with a diverse staff and client population.

• Proficiency and comfort with online meeting software such as Zoom and Microsoft Teams.
• Understanding of chronic medical conditions, homelessness, substance use, and mental illness.
• Knowledge of state, local, and federal entitlement and benefit systems.

• Travel within the boroughs via public transportation; ability to work from remote office locations.
• Access to email, phone, Zoom, and Teams.
• Compliance with agency confidentiality guidelines in remote workspace.

Competitive salary, generous tuition reimbursement, robust benefits package, and opportunities for professional growth.

Housing Works provides equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, or genetics. Housing Works complies with applicable state and local laws governing nondiscrimination in employment at all facilities.